Beginning of Success to Reach Health Care to Rural Communities with Extremely Low Resources and Access Problems

Shakuntala Chhabra

Social accountability in health care and medical education has been the hallmark of Kasturba Health Society, Sevagram, which runs Mahatma Gandhi Institute of Medical Sciences, Sewagram in Wardha District of Maharashtra, India. KHS also runs a Nursing School, Nursing College and Kasturba Vidya Mandir (School for children) in the same campus. Institute’s birth is also the consequence of social accountability by none other than Mahatma Gandhi, in the form of a 2 bedded dispensary in 1938 in the village Sewagram where there was a epidemic of Cholera and women and children were finding it difficult to get treatment. The sapling has now grown into a blooming tree with nearly 1000 bedded well equipped, Kasturba Hospital at Sevagram village in the centre of country. Expanding health services to Melghat region in Amravati, Maharashtra, is another step towards social accountability in health and education. The step was taken in view of rural communities sufferings.

In view of the problems of high maternal, perinatal, infant and child morbidity / mortality step was taken to help rural community. So government of India and Government of Maharashtra were approached with the proposal for Mother and Child / Multispecility Hospital at Utawali, but delays in the system were worrisome. So it was decided to do whatever was possible. Agriculture land was bought more than dozen no objections were procured and plans of hospital as expansion of existing institute in the nearly district was planned.

Fortunately a Mumbai based charitable trust “Shri Brihad Bhartiya Samaj” came forward with the generous donation for the building and major equipments for the proposed hospital. Before this hospital could be built a beginning was made on first January 2012 by alterations / additions in the existing building of a minihospital constructed by KHS, Sevagram some years back where a physician and ophthalmologist deputed by KHS were working. A make shift birth area, operation theatre for caesarean section, hysterectomy and other surgeries was done. Other needed changes were made in the building and equipments / instruments were procured. In the existing guest house in the campus, alterations and additions were made so that the health teams could stay for 24/7 for emergency services. A nearby hut was converted into kitchenette, dining area cum office. A mini-library and online Maharashtra University of Health Sciences library were made available for every one to remain updated. Sports too were arranged and mobile phones and televisions to make the life of health providers in the hilly forestry region with access problems little easy and to try to reduce the general reluctance of health providers to work in the region. Now since Feb 2016 a reasonably well equipped. Multispeciality Dr. Sushila Nayar Hospital in Utawali has come up with basic facilities available in much better way with reasonability comfortable place for the health provider team in the building. A building with 4 flats and some land have been procured in the vicinity keeping in mind needed accommodation during the development.

With the guidance, support and help of KHS/MGIMS, Sewagram the team of Obstetrician – Gynaecologist, Paediatrician, Anaesthetist, Physician, Medical Officers, Interns, Administrative Officer, Nurses with other paramedical staff have been managing emergencies and day to day problems in outpatient, inpatient and operation theatre, 24/7 days. While paramedical administrative staff has been exclusively appointed, doctors are deputed in rotation from head quarter, the medical institute in the near by district, a dozen doctors are always available. Author as officer on special duty with support of management and a big number of colleagues at base institute are trying since beginning their best, from buying agriculture land to health services now in a reasonably equipped hospital. Caesarean sections, minor and major gynaecological surgeries are being performed in addition to normal and instrumental births. Everybody is trying to give his/her best with whatever available in the given circumstances with limited resources. The very first caesarean section was performed on 21st January, 2012, mother and baby discharged healthy in a week. The first hysterectomy with removal of a uncommon cancer of ovarian tumor ‘Struma Ovari’ performed on 15 February, 2012 and the woman doing well, 6 years. Now services for prevention of blindness complete eye care are also being provided.

Everybody is trying to give his/her best with whatever available in the given circumstances with limited resources.

There is good understanding and cooperation between Sub District Hospital Primary Health centres of Government of Maharashtra and our centre.

While trying to do whatever we could, we have had many challenges, many practical difficulties and have also realised that though. nutrition, anaemia, poor health, are responsible for many problems, their causes are deep, in the social and economical conditions, in the nonavailability of food, in ignorance, when the food is available, gender bias, unemployment, addiction and many other issues. Hindrances also include lack of awareness, lack of resources to seek services at health facilities and their own faith concepts of traditional healing, beliefs and disbeliefs. Sometimes making the patient stay in the hospital for her own good or her child’s good is a tough job, testing the patience, the best of counselling skills and dedication. 

We realized within months of opening the hospital unless Community based services, community motivation, mobilization and behaviour change, were done not much was going to change. So a step was taken in this direction way back in Feb 2013, just a year after starting the services. Now seven nurse midwives provide community based antenatal services, advocacy about intranatal, postnatal, neonatal care in the villages. We started with 52 villages in February 2013 and 13 more were added from July 2013, a total of 65 till recent past. Later 35 more have been added from April 2016 and 40 more in August 2017, making a total of 140 villages. The team visits villages 5 days a week. Medical officers posted under Rural NGO posting scheme of the Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha used to run Community Based health clinics in these villages with the nurses, in rotation while services at base hospital at Utawali. However the current rules of postgraduates medical admissions with national eligibility examination, no medical officers are available. Some laws for some good spoil other good work. So interns of the Institute in the near by District at Sewagram  are posted in rotation for 15 days, task shifting. So while each NM visit their assigned village, once in a month, doctors run clinic in assigned villages by covering 7 villages in one visit by one doctor. Things will change. It needs some time before awareness will come in the tribal population and their many unlisted social and economical issues are really addressed.  

Now seven nurse midwives provide community based antenatal services, advocacy about intranatal, postnatal, neonatal care in the villages.

Diagnostic cum therapeutic camps have been made annual event. First camp was held in March 2012 with 226 patients, February 2013 the number was 1036, in 2014 February it was 1107, in 2015 it was1883 and 2016 it was 2197. In 2017 attempts were made to help differently abled and 216 needy were help. In 2018, 3872 Surgeries have been performed on camp days and left over cases are operated within days of camp, some at Utawali and complicated at the institute at Sewagram. Camp for Cleft lip Cleft Palate was also conducted in December 2014. Attempts are being made to help Elderly women and elderly men too for diagnosis and therapy of illnesses, including noncommunicable diseases, (Hypertension, Diabetes and Cancers) vision problems. Research was done with help from US based Global Health through Education and Service, (GHETS) Indo Canadian Institute from Canada. Now Mumbai based philanthropists including Jan Kalyan Trust help in services for elderly. Research about ‘Abortions’ under Indian Council Of Medical Research, New Delhi Disability Detection program was done and Aids, including Wheel chairs provided to nearly 225 people. Now beginning has been made for trying to make adolescent, young school drop outs learn skills to become self sufficient, with support from Jan Kalyan Trust Mumbai. Camps for cataract surgery are being done. 

Research is being done about effects of Bio-fuel mass on health of family specially mothers and new born with plans for providing and Chimneys related to Agriculture status and malnourishment, low body mass index, Anaemia, Vit A deficiency etc. There are plans for Family Life Education Program for Adolescents, Preconception literacy and care also, finding how Wellness can be created for them.

Presently the biggest need is of finances so that in the reasonably equipped, furnished hospital, free services can be provided to the real poor, especially mothers and babies in emergencies. It is not possible for KHS, Sevagram to provide free services to everyone without support. Though services are provided to everyone, who reports, irrespective whether the patient can pay or not, it is not possible to Declare free services due to lack of resources. Also financial support is needed for providing children the needed nutrition at home till the time they are in a position to become self sufficient. Major issues are also awareness of many things, access issues and safe water, working on their beliefs and disbeliefs.

____________________________________

Shakuntala Chhabra is an meritus Professor - Obstetrics Gynaecology, Chief Executive Officer - Woman Child Welfare, Officer Special Duty - Dr. Sushila Nayar Hospital, Melghat. In addition to DGO, MD, Diploma - Advanced International Maternal Health Sweden, Certificate Courses- Maternal Child Health, U.K, Problem Based Learning- Netherlands, others- Logistics Management, Teaching Training, Human Resource Management etc. Receive the awards: FIGO’s Distinguished Community Emergency Obstetrics, Best Teacher, MUHS, Nashik. Short term WHO Consultant, Technical Consultant, Technical Temporary Advisor - WHO. Supervisor for SIDA. Member of Women’s Health Task Force, Network TUFH, USA. Member of World Rural Health Council 2018. Special Interest- Maternal health, Social Obstetrics, Gynaecological cancers, Health Professionals education.

Curated by Ana Júlia Araújo and Mayara Floss

On my Skin

On my Skin

She opened the door of the health unit almost sensing something that morning. In the Rural Health Unit, about 100 kilometers away from the nearest reference center. A newly appointed doctor....and the farmers of the region saw in those hands a ray of hope. "The doctor listens to us."

Maybe this was the beginning of a cry about the future on her face. When she was in the office with another patient, somebody knocked the door, "Doctor, please come fast". The nurse was already gloved, a woman in great pain, laboir pain. Upon touching down the cervix, it was 5cm dilated. Fetal heartbeat flickering and Ineffective contractions.

Labor without progression was sensed. Oxytocin, orientations, everyone entering the small emergency room. Got everyone out of there to take a deep breath and called the 911.

"The ambulance can only get there in two hours, it is in another displacement." The calculation was not difficult... Two hours to come plus two hours to cover the 100km made 4 long hours. Can we handle it? Will the baby be born before that? We ask for priority, but the whole state needs priority.

Deep breathing, medications, salines, change of position, but still it is only 6cm of dilation in the first hour. The Fetal Heart Beat slowed down. They call the ambulance. "I need it for now." It doesn't arrive.

It did not come, it did not happen, it did not progress and it was not born.

Some colleagues would say, "it is her fault that she chose to work where she has no recourse". But is there a way to have a hospital in the countryside? To have an anesthetist team in the middle of the green of the corn? To have a team with obstetrician? Pediatrician? There, where the soy is planted?

Several will condemn "it is the doctor's fault, who went there," but would the unborn child stop herself being born or would the mother stop going into labor because they were in the countryside? Would the countryside stop existing just because there are no qualified professionals in it?

The baby was not born, the baby did not survive. Everyone hears the fetal heartbeat fade away without recourse, no training, no legislation, no doctor adequately trained for more than 60% of Brazil's population living in rural areas. While the ambulance did not arrive, a sigh, a tear.... A fatality? Could we have avoided this?

From birth to mourning. To err is human, to kill and to die is human too. But a doctor in the rural area without training is inhumane.

Warm regards,
Mayara Floss

Review by: Nisanth Menon
Translated into English by: Bianca Silveira

Posted and Edited by: Ana Júlia Araújo

Link to Portuguese text: http://balsa10.blogspot.com/2018/05/na-minha-pele.html?q=mayara+floss

Mayara Floss is a young doctor working in a rural area: Cunha Porã (SC), Brazil. She Co-creator of project 'Health Education League'.  She is the creator of the Rural Family Medicine Café to provide a forum to discuss Rural Health – a forum for students, young doctors and experienced professors and GPs from all world. She is the student representative of the WONCA Working Party on Rural Practice. She also co-created with Pratyush Kumar the project 'Rural Health Success Stories' and writes a weekly blog of Popular Education, Arts and Health - the Ferry Street of 10.

Healthcare in Kerala : My observation

....having stayed in kerala during my graduation , I found Kerala to be a society full of paradoxes, rather hypocritical to an extent.

Whereas on the one hand you have the best literacy rates and the wow health standards at par with the developed world, on the other you have almost near zero entrepreneurial ventures no industry very limited opportunities of employment outside the government .

One of the highest suicide rates in the country and almost all families have an earning member overseas/outside kerala sending in the dough.

On the one hand female literacy rates are the highest in the country on the other ladies venturing outside their home after sundown were looked down upon,

On the one hand you have the matriarchial society on the other hand ladies are not allowed in the sabrimala temple ( a place of worship in Kerala)

Whereas on the one hand you will not find any coolies on the railway stations but a good chunk are manual labourers in the society.

Whereas you will find them to be admitting to be less than willing to do anything yet their professionalism specially in healthcare is beyond compare, their dedication , zeal and commitment unparalleled.

Health standards were achieved in my opinion because of exemplary societal acceptance of the role of the ladies in the healthcare field specially in the domain of Nursing and teaching.

Whereas men folk ventured to search for employment opportunities beyond Kerala, i.e in the Gulf, America, Europe, or even in other indian states,the women folk continued to manage the native front and ensured education and good healthcare to their children.

As a result even though the governmental expenditure on health was trivial, the out of pocket healthcare was flourishing.

Nothing succeeds like success! once they had carved out a place for their state in the health standard arena they took upon themselves on a war footing as a matter of immense pride to keep it that way and once achieved the government too started to patronise the healthcare in a bigger manner.

If you have travelled through Kerala you would realise that it is an urban village from the northern most district (Kasarkode) to the southern border (Thiruvananathapuram)with almost universally similar facilities all over.

This was probably due to a paradigmal shift by the policy makers regarding resource allocation to local governing bodies called panchayats around 1996, where almost 40 percent of the states available funds were at the disposal of these local bodies for capacity building and development, as per local needs.

Open door policy viz for education in english and hindi ensured education to kids that was utilisable beyond kerala, at the same time not letting go their tradtional cultural traditions i.e mohiniattam, kathakkali, and their gaanamelas,

Notwithstanding what the world said they continued to use coconut oil for cooking relying on their cultural wisdom,only now the entire world is marketing virgin coconut oil for cooking and as cure for some forms of dementia.

Coconut,coffee,cardamom and rubber which were their cash crops peculiar to the weather there continued to attaract world attention because despite all the mechanisation most of these crops continued to be grown traditionally and had their quality and genepool maintained.

Traditionally they eat parboiled rice which is now emerging as a recommendation for diabetics.

With the IT revolution the beauty of kerala became popular and Kerala an important destination for medical tourism specially for the Maldivians and the Lankans. like begets like !! once the dollars started trickling in the industry veterans pumped in even more to ensure world standards.

So,what probably started as a mundane chore of life evolved as the feather in the cap of the nation leave alone Kerala .

Regards

Dr Hemant Saluja

Its just God's miracle, we are just medium...

         Hello friends.Me Dr.Suhas and my wife Dr. Prerna are specialist by degree but generalist by choice.We both have humble rural background and upbringing.Hence after our post graduation we moved to rural set up for practice as we believe we have many dues towards society and community who helped us to be a good doctor.

        In rural peripheral setup you have a new day new challenge.There are many stories till now in one year. 

But the most interesting one is the 28 year female diagnosed with unexplained infertility for 8 long years. She was investigated & treated at several Super speciality setups at Mumbai, Pune, Nasik, Malegaon, Aurangabad. 

     She even underwent multiple times for diagnostic laparoscopy, hysteroscopy, IUI, IVF & her male partner was also treated for low sperm count in last 8 years but failed every time. Spent lacs of rupees for treatment but every time result was unsuccessful. Husband being rickshaw driver, due to mental frustration gave up hope on for not being able to  become a father. 

               Interesting fact is that the couple was none other than our hospital staff worker's son & daughter in law. 

After we started practice in rural setup, the staff told the story about her son & daughter in law. The couple meanwhile consulted us. Selective investigations were done as all the previous investigations were normal. We studied the case very thoroughly and with help of expert opinion of Dr. Prerna the patient conceived within a month. Her UPT came positive for the first time. 

           The happiness which we saw on her face was priceless. After proper care of thorough 9 months pregnancy she delivered a male child on 23/4/17. Staff worker's son literally cried with happiness. He told us that we are everything for him. And we told him its just God's miracle, we are just medium...

Author

Dr. is Dr.Suhas Pawar is (MS Gen.Surgeon) and his wife Dr.Prerna Pawar MBBS,DGO.They run a rural hospital named Saibaba Hospital, Satana,Nashik. Both belogs to humble rural background and are passionate to provide all super speciality services to rural people in there own community.This shall reduce there trouble to cope up with city urban life.

Grief and resilience on a remote Pacific Island

Dr Nini Wynn

I worked as the sole doctor for five years on one of the outer islands of the Southern Cook Islands, a Pacific Island Nation. The hospital with eight-beds had basic facilities and diagnostics only.  We could not provide advanced Cardiac Life Support because there was no Defibrillator. During my stay on the island, I met a family of five: father, mother and three children – two daughters and one son, who faced three deaths in 4 consecutive years.

The 8 year old boy became ill and when it became apparent that he was not improving he was transferred to Rarotonga, the main island, an hour’s flight away. He was found to have an abdominal lump and was referred on for further investigations and management to Auckland, New Zealand, which involved a 4 hour flight and crossing a national border. 

He was diagnosed there with Nephroblastoma (Wilm’s Tumor). Prognosis was very poor and he died at the Auckland Hospital, far from home. The whole family was devastated and shattered. His body was brought back from New Zealand to the Cook Islands to be buried. Blessings were received after this boy passed away and his mother gave birth to another son. They were all so happy to have a new member in the family. However, a year later, one of their daughters was killed in a motor vehicle accident; she fell off the moving car on the way back from school, sustained a severe head injury and was killed instantly. She was brought into the hospital with no sign of life. The parents were informed and they arrived at the hospital hoping against hope. Her mother held her tightly in her arms and said that she loved her so much - she did not even get a chance to say a few words before her daughter’s last breath. Her father was quite a strong man and we did not see him crying, but we all knew that he must have been crying in his heart.  

Bad luck came in a row to that family –the following year the father became sick. He was 54 years old at that time he presented with epigastric pain and weight loss. He had had the pain for quite a while but did not seek medical attention. Clinically, no positive findings were found and he was referred to Rarotonga for further investigation. There is plain X-ray and ultrasound at Rarotonga hospital but no complex imaging i.e no CT scan or MRI. A gastroscopy was done which showed gastric outlet obstruction and a diagnostic biopsy came back as ‘normal gastric mucosa’. However, his condition did not improve and serious discussions followed with the patient, family and the health team. The possibility was that the biopsy taken might have been insufficient and missed a pathology. There were some issues and controversies during the process of his referral, which caused delays in sending him to tertiary care. When he was finally transferred to Auckland, New Zealand he was diagnosed with inoperable carcinoma of stomach and he died six months later in NZ. He was not well enough to travel home. 

I was amazed at the wife and the mother who had faced three deaths in a row - she was so strong and she dealt with her grief with a real will, whilst taking care of the rest of the family- herself, her eldest daughter and the last born son. She had faced expected and unexpected death. She travelled twice to Auckland and spent precious time with her late son and late husband during the last days of their lives. She respected her husband’s wishes to get treatment with traditional medicine for his cancer, because he believed that it could heal him. He was in a denial stage. As the breadwinner of the family, he had a strong will that he must live on. His priority was his family. He did not want to leave his wife and two children. Even though his wife knew the reality-that her husband was living in his last days, she never argued or went against his wishes. The small community of Cook Islanders based in Auckland, gave her and the family help and support in different ways; psychological, spiritual and financial, during her difficult times. His family accompanied his body back to his home island where he was buried close to his ancestors and his daughter.

When I look back at her story, some questions arose in my mind; would there have been any difference in survival and prognosis of this man and his son if they had lived in a big city with specialist care and advanced modern medical technology? Would the man have survived if the referral had been done more urgently? Is this an example of the health inequality/disparity for people living in rural remote areas? If it is so, could there have been a huge difference to this woman’s life?

What shines through is the resilience shown by the family – the very strong sense of belonging to a place – their island - wanting to be there whether in life or death. This love of their home and their people is perhaps the most important.

About the author

My name is Nini. I live in the Cook Islands, a small Island Nation in the Pacific. My work is in the Outpatient and Emergency Department at Rarotonga Hospital. Rarotonga is the main island of the Cook Islands. Prior to that, I worked in a small hospital on one of the Outer Islands which provides primary health care for the local community.

Currently I am working in a rural hospital in NZ to complete the two six-months placement as a part of the newly established Cook Islands General Practice Training Programme. This programme started in 2014 and was developed by the Cook Islands Ministry of Health in partnership with the University of Otago and the RNZCGP. Before this doctors in the Cook Islands had no Family Practice training pathway."

My story is based on a social and cultural concept on death and dying in rural and remote community – from the time I was working on the Outer Island.